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An 11 year old male arrives to the ED accompanied by this father. The front desk staff alert you that “He is not breathing right.”
Upon visual assessment, you notice that the patient’s pallor is grey. He is grunting with each breath and has nasal flaring. You can see his shoulders move when he takes a breath. When his shirt is removed to put him in a gown, you can see he is using accessory muscle to breathe. 
You ask his name, but he is unable to respond. He father responds for him, “Kosi.”. You auscultate his lungs and hear wheezing in expiration. 
His dad says, “Kosi is having trouble staying awake.”

 

1. What is your first action? State your rationale for choosing that as your first action. 

2. What 3 nursing diagnosis are appropriate for this patient? 

 

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SCIENCE
HEALTH SCIENCE
NURSING
NURS 265